Katepa-Bwalya et al.

International Breastfeeding Journal (2015):

DOI 10.1186/s13006-015-0033-x

RESEARCH Open Access

Infants and young children feeding practices and

nutritional status in two districts of Zambia
Mary Katepa-Bwalya1*, Victor Mukonka2, Chipepo Kankasa3, Freddie Masaninga1, Olusegun Babaniyi1
and Seter Siziya2

Abstract
Background: Appropriate feeding is important in improving nutrition and child survival. Documentation of
knowledge of caregiver on infant feeding is scanty in Zambia. The aim of this study was to describe feeding
practices and nutritional status among infants and young children (IYC) in two districts in Zambia: Kafue and
Mazabuka.
Methods: A cross-sectional study was conducted between January and March 2006 using both quantitative and
qualitative methods. A questionnaire was administered to caregiver of children aged under24 months. Lengths and
weights of all children were measured. Focused group discussions were conducted in selected communities to
assess parents or guardian knowledge, attitude and practice related to infant feeding.
Results: A total of 634 caregivers (361 from Kafue and 273 from Mazabuka) participated in the study. About 311/
618 (54.0%) of the caregiver knew the definition and recommended duration of exclusive breastfeeding (EBF) and
when to introduce complementary feeds. Two hundred and fifty-one (81.2%) out of 310 respondents had acquired
this knowledge from the health workers. Only 145/481 (30.1%) of the respondents practiced exclusive breastfeeding
up to six months with 56/626 (8.9%) of the mothers giving prelacteal feeds. Although 596/629 (94.8%) of the
respondents reported that the child does not need anything other than breast milk in the first three days of life,
only 318/630 (50.5%) of them considered colostrum to be good. Complementary feeds were introduced early
before six months of age and were usually not of adequate quality and quantity. Three hundred and ninety-one
(64%) out of 603 caregivers knew that there would be no harm to the child if exclusively breastfed up to six
months. Most of the childrens nutritional status was normal with 25/594 (4.2%) severely stunted, 10/596 (1.7%)
severely underweight and 3/594 (0.5%) severely wasted.
Conclusions: The caregiver in the communities knew about the recommended feeding practices, but this
knowledge did not translate into good practice. Knowing that most of the mothers will breastfeed and have heard
about appropriate breastfeeding, is important in the development of sustainable strategies required to improve
feeding practices and, thus, nutritional status of children.
Keywords: Exclusive breastfeeding, Infant feeding practices, Nutritional status

* Correspondence: bwalyam@who.int
1
World Health Organization, Country Office, Lusaka, Zambia
Full list of author information is available at the end of the article

2015 Katepa-Bwalya et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the
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Katepa-Bwalya et al. International Breastfeeding Journal (2015):
Background
The Zambia Demographic and Health Surveys (ZDHS)
have shown a declining trend in child mortality rates [1].
However, current rates remain unacceptably high, which
necessitates concerted efforts to increase the coverage of
known cost-effective and low-cost interventions to en-
able Zambia attain the Millennium Development Goal 4
(MDG 4) target of reducing child mortality from 167 per
1000 to 64 per 1000 live births. A key issue that needs to
be addressed in trying to meet MDG 4 is under nutrition
which still underlies almost a third of all deaths in chil-
dren less than five years [2]. Estimates indicate about
35% of child death and 11% of total global disease bur-
den are due to poor nutrition [3]. According to the 2002
Zambia Demographic and Health Survey, 42% of chil-
dren dying had underlying malnutrition [4]. Appropriate
feeding practices are fundamental to survival, growth,
development, health and nutrition of infants and chil-
dren and to the well-being of the mothers. There is suffi-
cient evidence of cause effect for certain preventive
interventions such as exclusive breastfeeding in the first
six months in the prevention of diarrhoea, pneumonia
and neonatal sepsis; complementary feeding in prevent-
ing diarrhoea, pneumonia, measles and malaria; and
vitamin A in prevention of diarrhoea [5]. Interventions
including breastfeeding, complementary feeding, vitamin
A and zinc supplementation could save about 25% of
total deaths in under-five age group [5]. Breastfeeding
alone has been shown to decrease the child mortality by
13%. Promoting appropriate infant feeding practices
such as early initiation of breastfeeding and exclusive
breastfeeding for up to six months, even in the era of
HIV and AIDS, is an effective strategy for improving
child survival. Even though breastfeeding is universally
practiced in Zambia, early initiation of breastfeeding oc-
curs in only 57% of cases. Nine percent of infants receive
prelacteal feeds. The national median duration of exclu-
sive breastfeeding is three months. This shows that a sig-
nificant number of infants still do not benefit from
optimum breastfeeding practices. In sub-Saharan Africa,
31% of children are exclusively breastfed for up to six
months [6]. Infants aged zero to five months who are
not breastfed have a higher risk of dying as compared to
their counterparts who are breastfed [7-9]. Exclusive
breastfeeding has been shown to decrease the rates of
HIV (Human immunodeficiency virus) transmission as
compared to mixed feeding [10]. In Africa most women
breastfeed their children for up to two years of age, but
seldom practice WHO (World Health Organization) rec-
ommended exclusive breastfeeding up to six months of
age [11-13]. This is in part due to lack of knowledge on
the protective effects of exclusive breastfeeding for the
recommended duration [14]. The zero to five months
exclusive breastfeeding rates for Zambia has steadily
Page 2 of 8
increased from 13 to 61% in 1992 and 2007 respectively
[1]. The median duration of breastfeeding in Zambia is
reported to be 21 months. This is below the WHO/
UNICEF optimum recommendation of breastfeeding for
two years and above.
Information on parents or guardians knowledge and
practice on infant feeding is limited in Zambia. This
study aimed to describe feeding practices and nutritional
status among infants and young children (IYC) in two
districts in Zambia, Kafue and Mazabuka. The informa-
tion gathered seeks to strengthen delivery of infant and
young child feeding (IYCF) interventions and thus im-
prove nutrition status and child survival.
Methods
Study design and data collection
This was a cross-sectional study that combined qualita-
tive and quantitative methods. Qualitative data on infant
feeding practices was obtained through focus group dis-
cussions (FGD), semi-structured interviews and key in-
formant interviews in Mazabuka.
For the quantitative part of the study, a questionnaire
was administered to the caregiver by 22 trained research
assistants recruited from Kafue and Mazabuka. The
questionnaire administered to caregiver collected infor-
mation on the general characteristics of the participants
and their children, knowledge, attitude and practices on
early initiation of breastfeeding, colostrum, exclusive
breastfeeding for up to six months, introduction of com-
plementary foods and types of complementary feeds,
breastfeeding problems and how they are addressed and
support for breastfeeding. The weight and length of the
children were measured using a salter scale and length
board respectively. Research assistants were trained over
a two day period and the quantitative study was con-
ducted between January and March 2006.
Study sample
The mothers and their infants or toddlers were the pri-
mary targets. If the mother was not at home at the time
of the survey, the questionnaire was administered to the
closest guardian of children aged zero to twenty three
months who was at home.
Nine FGD were conducted in Mazabuka among women
who were younger than 25 years and women older than
25 years. Eighteen in depth interviews with fathers, grand-
mothers, health workers and traditional birth attendants
were conducted.
Sample size and sampling
The sample size was determined using the 2002 Zambia
Demographic and Health Survey exclusive breastfeeding
prevalence rate of 40% [4] at a confidence level of 95%.
Katepa-Bwalya et al. International Breastfeeding Journal (2015): Page 3 of 8

Considering a response rate of 90%, the minimum re- Table 1 Characteristics of the study population
quired sample size was estimated as 450. Mazabuka Kafue
(Total = 273) (Total = 361)
Sampling % (n) % (n) p-value
In urban areas participants were randomly selected. How- Sex of head of family
ever, in the rural areas, a convenient sample was collected
Male 84 (226) 92 (327) 0.003
because the rural households were scattered over large
hard to reach geographical areas. Females 16 (43) 8 (30)
Age of caretaker (years)
Study site <19 15 (41) 14 (51) 0.96
The study was conducted in two settlements (urban and 20-29 59 (161) 59 (212)
rural) in Mazabuka district and similarly, two settle- 30-39 22 (60) 23 (83)
ments in Kafue districts. Baseline data was being col-
40-59 3.3 (9) 4 (14)
lected in Mazabuka for an intervention study that was to
be implemented the following year. Kafue was conveni- Caretaker-child relationship
ently added as it is a district near Mazabuka. Mother 98.2 (268) 99 (357) 0.368
Other 1.8 (5) 1 (4)
Data management and analysis Marital status
The Principal Investigator supervised the data collection Married 81.8 (220) 85 (308) 0.265
and management. Two data entry clerks entered the
Widowed 4.1 (11) 2 (8)
same data simultaneously. Microsoft Excel and SPSS
were used for data entry and analysis respectively. Qual- Divorced 3 (8) 2 (8)
ity control audits of all data in the database were made Separated 1.1 (3) 2 (8)
daily after entering data from each field exercise. Single 10 (27) 7 (25)
Primary outcome variables were breastfeeding rates, ex- Educational level-caretaker
clusive breastfeeding rate and duration of breastfeeding; None 5.2 (14) 11 (38) <0.001
and secondary outcome variables were caregiver know-
Primary 50.6 (137) 67 (239)
ledge of complementary feeding. The Chi square test was
used to compare proportions between districts at the 5% Secondary 38 (103) 23 (81)
significance level. Tertiary 6.3 (17) 0 (1)
Age distribution of the children
Ethics <6 months 28 (76) 31 (111)
The study received clearance from the University of 6 11 months 26.2 (71) 30 (107)
Zambia Research Ethics Committee and the Ministry of
>12 months 45.8 (124) 39 (140)
Health through the district health management teams
(DHMT) in Kafue and Mazabuka. Individual informed
written consent was obtained from all participants of the of them reported to have started breastfeeding within the
study before any instrument was administered to them. first hour after delivery. During focus group discussions
most mothers stated that they breastfed their child within
Results an hour after delivery. Their response was as follows: You
All caregiver in the selected households consented to breastfeed your child when you finish giving birth. In the
participating in the survey. A total of 634 (273 from FGD conducted in urban area mothers emphasized that the
Mazabuka and 361 from Kafue) caregiver participated in child needed to cry before the child is put to the breast.
the study. The questionnaire was administered to all When I deliver, if my baby has not cried, then I dont breast-
identified caregiver residing in the selected households. feed. But if she/he cries, then that is when I breastfeed. Only
621/630 (98.6%) of the caregivers were the mothers of 34/267 (12.7%) of the respondents in Mazabuka and 22/359
the children. Educational level of the parents/guardian (6.1%) in Kafue (p = 0.004) gave prelacteal feeds. The re-
was significantly (p < 0.001) higher in Mazabuka than in spondents were taught information on the need to initiate
Kafue (Table 1). About 365/629 (58.0%) of the children breastfeeding in the first hour and the avoidance of prelac-
seen were infants. teal feeds during the focused antenatal clinic (FANC) and
under five clinic (U5C) visits. FGD conducted in the rural
Initiation of breastfeeding areas some of the discussant said that there was no need to
Six hundred and twenty-one (99.4%) out of 625 mothers re- give anything before starting to breastfeed whereas others
ported having put their infants to the breast. The majority felt there was need to give a little water . . . I normally give
Katepa-Bwalya et al. International Breastfeeding Journal (2015):
water. It makes the throat wet. The throat should not be dry,
because the milk at that time has not yet started coming
out.
About half of mothers in both districts talked posi-
tively about colostrum. They indicated that it was good
for the child, while about a third of the caregiver in both
Mazabuka and Kafue thought that the colostrum was
bad for the child. The rest of the mothers did not have
an opinion about the colostrum. Respondents in the
urban FGD talked about colostrum as appearing like
water and not milk. They indicated that it was good
and protected the baby from diseases. They had obtained
information on colostrum from the elderly people in the
community and the health workers during health talks
given at antenatal clinic visits. In the rural areas, a few
of the discussants reported squeezing out and discarding
colostrum as it was thought to be dirty. They reported
that colostrum was not milk but it brought in milk.
Significantly more caregivers in Kafue (254/261, 97.5%)
than in Mazabuka (317/348, 91.1%) reported that the
child does not need anything other than breast milk in
the first three days of life (p < 0.001).
Exclusive breastfeeding
There was a significantly higher (p < 0.001) proportion of
children who were exclusively breastfed up to four months
in Kafue (207/301, 68.8%) than in Mazabuka (98/186,
53.0%). The rate of EBF dropped at age six months (56/181,
31.1%) in Mazabuka and (89/300, 29.9%) in Kafue). The
FGD showed that mothers were generally aware of the con-
cept of exclusive breastfeeding (EBF) and most of them had
a positive perception about it. The main reason given in
favour of EBF was that the intestines of the infant were too
immature and small to handle other foods and the baby
would get sick and have stomach pains if given other foods.
About 391/606 (64%) of the caregiver in both districts knew
that no harm would come to the child if he/she was exclu-
sively breastfed up to six months and that the breast milk
was enough for the child. Most of the discussants in the
FGD reported that the baby can grow healthy on breast milk
alone and can survive for six months. The main barrier to
practicing EBF was that the caregiver feared that babies
would not be accustomed to other foodstuff in case the
mother is not able to breastfed due to illness or death. Some
discussants indicated that mothers may not have adequate
breast milk and would need to introduce other feeds early.
For such problems, increasing the food intake and intake of
locally brewed non-alcoholic maize mealie meal based
drinks such as munkoyo and chibwantu were considered
to be plausible ways of increasing breast milk production.
None of the discussants in the FGD discussed the risk of
HIV infection related to mixed feeding or the importance of
EBF in this era of HIV.
Page 4 of 8
Complementary feeds
316/486 (65.0%) caregivers knew that other foods should be
introduced at six months. There were significantly more
caregivers in Mazabuka as compared to Kafue who knew
this (p < 0.001). Likewise, significantly more caregivers in
Kafue (288/360, 80.0%) than in Mazabuka (178/255, 69.8%)
reported that the child would show signs of being ready for
other foods (p = 0.004). Some of the signs identified were
crying a lot, an increase in appetite and wanting to breast-
feed more often than usual. Other discussants felt that milk
was a liquid and not food and the child needed food to
satisfy his/her hunger. The most commonly introduced
complementary food at six months was maize mealie por-
ridge. What was given in addition to the porridge was
dependent on the economic status of the discussants.
Addition of groundnuts, pounded small fish (kapenta), oil,
sugar, egg (especially the yolk), bean soup, and milk to the
maize meal porridge was common. FGD showed that care-
givers residing in the urban areas who could afford, intro-
duced a commercially pre-cooked cereal called cerelac
before the maize meal porridge. This was mentioned in
both the urban and rural FGD, although the latter discus-
sants said that they could not afford to buy the cerelac.
Fruits, commonly bananas and oranges, were mentioned as
being common complementary foods that were given to
children.
Continued breastfeeding
Eighty nine percent (558/627) of caregivers were breastfeed-
ing their children at the time of the interviews. They all re-
ported to be breastfeeding during the day and night.
Duration of breastfeeding for those who had stopped breast-
feeding ranged from one to twenty-two months. The major-
ity stopped breastfeeding because they believed breast milk
was not enough or that the child had lost interest in breast-
feeding. The median age for stopping breastfeeding was 18
(Q1 = 16, Q3 = 20) months in both districts. The discussants
in the FGD (both rural and urban) reported to have stopped
breastfeeding their children between 18 and 24 months. The
majority felt that at this age, the child does not need breast
milk. Ways of determining if the child was old enough to be
weaned included the following: child being able to walk and
obey requests like bringing an item to the mother. In
addition some children were weaned off if the mother be-
came pregnant. A number of the discussants reported that
they took the child to the grandparents when they wanted
him/her to be weaned off breast milk. When a child wants
to stop, you take him/her to someones place - Like at his
grandparents place or if I have a big [elder] sister or brother
I can take him there . One discussant reported: No, like
me, when I want to wean my child, I went to seek advice
from the health centre on what I should give my baby. So, I
was told to buy drinks . Drinks talked about were locally
Katepa-Bwalya et al. International Breastfeeding Journal (2015):
made maize mealie non-alcoholic based drinks and brews
like maheu, chibwantu and umunkoyo.
Support for breastfeeding
The father of the child was identified as being the main
source of financial and moral support pertaining to infant
feeding. Other sources of support identified were relatives
like the grandparents and aunties. Some of the discussants
felt that older people who had experience with looking after
children could give valuable advice although some of the ad-
vice was incorrect. They indicated nurses to be an important
source of support as they were very knowledgeable and
shared their knowledge during the antenatal and under five
clinic visits.
Difficulties in breastfeeding
Of 617 respondents, 572 (92.7%) did not report any difficul-
ties in breastfeeding. Of the few that reported difficulties,
the common problems were pain when breastfeeding, infec-
tion, breast abscess and sore nipples. In addition to these
difficulties, they identified lack of milk, or mother being too
busy to breastfeed, or mother being sick from HIV or the
breast milk being bad. When asked about whether a child
should stop breastfeeding in the event of the mother falling
sick, the majority in the FGD said that it depended on the
type of illness. It was felt that the mother should stop breast-
feeding if she had diseases like severe malaria, tuberculosis
and acquired immune deficiency syndrome (AIDS). On the
other hand, if the child was sick, the majority of the women
felt that continuing breastfeeding was good as breast milk
gave the baby strength and energy as well as protected the
child and prevented the progression of the childs illness.
About one third of respondents who had difficulties whilst
breastfeeding went to a health facility to seek help. When
asked who they would consult if they had breastfeeding
problem, those who did not have problems reported that
they would seek help from a health worker (523/607, 86.2%)
followed by the maternal grandmother (50/607, 8.2%). In
addition to the health worker, discussants in the rural areas
indicated the grandmother as a good source of information
on solutions to breastfeeding problems. The mothers and
older discussants felt that someone who had experience with
breastfeeding could provide valuable advice to those who
were having problems with breastfeeding. The rural discus-
sants did not have easy access to health workers. Therefore,
they relied more on the older population with more experi-
ence as compared with their urban dwellers.
Knowledge on infant and young child feeding
About 50% (311/618) of the mothers had been informed
about breastfeeding and the information was mostly ob-
tained from the health workers (251/310, 81%), followed by
maternal relatives, especially the mother. Friends, commu-
nity health workers and the radio were also an important
Page 5 of 8
source of information about breastfeeding. The content of
information received consisted of putting the newborn im-
mediately to the breast after delivery, correct positioning
techniques of baby when breastfeeding, exclusive breastfeed-
ing, duration of the whole breastfeeding period and when to
introduce other foods. The focus group discussions also
reflected the fact that the knowledge on infant feeding prac-
tices was obtained mostly from the health workers and most
of the discussants generally knew that exclusive breastfeed-
ing was advocated for six months and thereafter other feeds
could be introduced.
Nutritional status
The majority of children (523/625, 83.7%) observed dur-
ing the study period reported no illness and were of
good nutritional status. Of the children seen 4.2% (25/
594) had severe stunting; 1.7% (10/596) were severely
underweight and 0.5% (3/594) had severe wasting.
Table 2 shows that underweight was significantly associ-
ated with mothers education status (p = 0.047) and marital
status (p = 0.037). A higher proportion of males (54/267,
20.2%) were underweight compared to females (32/253,
11.2%). No significant associations were observed between
wasting on one hand and schooling and marital status on
the other. Stunting was only significantly associated with
schooling (p = 0.011).
Signs and prevention of malnutrition
In the FGD, the discussants knew the signs of malnutri-
tion and described it as condition where a child has
swollen face, feet and abdomen. Generally there was
good knowledge on the fact that malnutrition is caused
by child not taking adequate food although no one men-
tioned the fact that the quality of the food played an im-
portant role in the causation of malnutrition.
Knowledge about the food groups was generally good
with the majority of the mothers mentioning the three
main food groups. The discussants from the rural setting
though knowledgeable about the food groups could not
practice giving the child different types of food as com-
pared with the discussants from the urban setting.
When asked about prevention of malnutrition, the dis-
cussants talked about giving a lot of porridge and making
sure that the child is always satisfied whilst the focus for
others was on making sure that the child never got cold
food. A few mentioned giving the child food like vegetables,
porridge, groundnuts, local drink (umunkoyo), oranges, ba-
nanas and bean soup as a good way of preventing malnutri-
tion. The importance of giving varied diet with all required
nutrient in the right proportion was not highlighted. Com-
mon foods mentioned that could be used in treating mal-
nutrition were porridge and groundnuts, vegetables, and
body building food.
Katepa-Bwalya et al. International Breastfeeding Journal (2015): Page 6 of 8

Table 2 Characteristics of caretakers and the children who were malnourished in the two districts
(Mazabuka and Kafue) combined
Stunting Underweight Wasting
Characteristics Total n (%) Total n (%) Total n (%)
Sex of child
Male 266 61 (22.9) 267 54 (20.2) 295 18 (6.1)
Female 250 42 (16.8) 253 32 (12.6) 271 13 (4.8)
p-value 0.154 0.049 0.519
Schooling
0-7years 298 74 (24.8) 303 62 (20.5) 333 23 (6.9)
>7 years 171 22 (12.9) 168 20 (11.9) 182 6 (3.3)
p-value 0.011 0.047 0.106
Marital status
Married 431 83 (19.3) 440 65 (14.8) 476 23 (4.8)
Not married 85 20 (23.5) 80 21 (26.3) 90 8 (8.9)
p-value 0.47 0.04 0.15

Care seeking
Several mothers mentioned that they would take their
child to the clinic or hospital and get help from the nurses.
Immediately you see the signs you take the child to the
clinic where they can help you, they will also tell you the
kind of food to give the baby. Only a few mothers said that
they did not know what they would do if their child be-
came malnourished.
Discussion
Initiation of breastfeeding
Although it was reported that prelacteal feeds were given to
the newborn infants, all the mothers initiated breastfeeding
at birth. This compares well with the results from the 2002
and 2007 ZDHS and other studies within the region
[1,4,15]. Not all the mothers were aware of the protective
nature of the first milk (colostrum) and tended to discard it
citing reasons such as milk being bad. This practice was
also observed in another study conducted in Tanzania [16].
Infants given colostrum and breastfeeding have fewer epi-
sodes of diarrhoea compared to those that are not [12]. Lack
of knowledge on the advantages of giving newborn colos-
trum can lead to mothers discarding the first milk.
Exclusive breastfeeding
In this study, a large proportion of infants less than four
months of age, were reported to have been exclusively
breastfed. In the 2002 ZDHS and a report on assessment
of infant feeding practices conducted by Norwegian
Programme for Development, Research and Education
(NFNC) in Zambia in 2003, fewer children (less than 50%)
in Mazabuka and in Kafue were exclusively breastfed [17].
Most of the caregivers knew about exclusive breastfeeding
up to six months of age and were generally knowledgeable
about what and when to introduce other foods to the in-
fants. Despite this high level of knowledge about exclusive
breastfeeding for up to six months, it did not translate into
the communities actually putting this into practice. In both
communities the rates of exclusive breastfeeding up to six
months was low. The majority of those who did not exclu-
sively breastfeed for up to six months provided some water
to the infant early in the child s life. This concurs with the
findings of the ZDHS reports [1,4]. In other studies con-
ducted in the African sub-Saharan region it was reported
that water alone or mixed with sugar were offered even to
newborn infants and light porridge was also offered to in-
fants as young as two months [11,18].
Complementary feeding
During focus group discussions, some discussants had a per-
ception that introducing the baby to solid feeds needed to
be preceded by a period of first feeding the baby on thin
porridge made from maize meal. This meal is usually not
enriched with other foods. The complementary foods com-
monly introduced do not meet the minimum standard of
recommended IYCF practices with respect to food diversity,
frequency of feeds and consumption of breast milk or other
milk or milk products. Only 37% of youngest children aged
six-twenty three months were fed in accordance to IYCF
practice minimum standard [4]. This study corroborates
other studies that showed that the feeds introduced are not
adequate in nutrition and tend to be low in energy and
micronutrients such as vitamin A, iron, zinc and other es-
sential nutrients [19-22]. Compliance with recommended
IYCF practices increases with mothers level of education.
Forty-eight percent of children whose mothers attended sec-
ondary school were fed according to the recommended
IYCF practices, compared with 32% of children whose
Katepa-Bwalya et al. International Breastfeeding Journal (2015):
mothers had no education [4]. In other studies, education
was found to improve adherence to infant feeding recom-
mendations and reduced childhood morbidity [11,12,23-26].
National reports showed the mean day time feeds in the
country to be seven but the mean night time feeds to be
about five [4]. A study conducted in Ghana, reported a high
frequency (21 times in a day) of breastfeeding, but feeds
were of a shorter duration [27].
Continued breastfeeding
The median age at which young children stopped breast-
feeding was 18 months which was slightly less than the na-
tional median age of 20 months reported in 2002 [4]. The
DHS from different countries in the sub-Saharan region
showed the median duration for breastfeeding to range from
18 to 25 months [18].
Support for breastfeeding
Fathers were mentioned to be important in supporting the
mothers financially and morally to breastfeed optimally.
They ensured provision of appropriate foods especially dur-
ing the weaning period. Nurses were identified as important
source of support for mothers or caretakers when they en-
countered difficulties pertaining to breastfeeding. Nurses
provided most information about infant feeding practices to
caregiver during the antenatal care (ANC) services and U5C
visits to expectant mothers. Information included know-
ledge on types of food to be introduced at six months.
Nutritional status
Most of the childrens nutritional status was normal with a
lower rate of severely stunted, severely underweight and se-
verely wasted as compared to national figures. In this study
malnutrition was significantly associated with the level of
education of the caretaker, which corroborates other studies
in Africa that showed the higher the level of education the
lower the prevalence of malnutrition [28-30]. In the 2007
ZDHS, education and wealth were inversely related to stunt-
ing, wasting and underweight.
Data showed that children born to mothers with pri-
mary level education were more likely to be stunted (49%)
than children born to mothers with more than secondary
education (21%), underscoring the importance of female
education. Early introduction to complementary feeding
was associated with a lower weight for age and increased
risk of respiratory infection in a study done Malawi [25].
In this study the caregiver in the community knew about
the recommended feeding practices, but this knowledge
did not translate into good practice. Adherence to the rec-
ommended feeding practices by the children caretakers
has beneficial effect on the growth of the infant and young
child [31].
Page 7 of 8
Limitations
Funds did not permit other types of sampling especially in
Mazabuka where most of the rural population was scat-
tered over a large geographical area.
Conclusion
The caregiver in the communities knew about the recom-
mended feeding practices, but this knowledge did not
translate into good practice. Knowing that most of the
mothers will breastfeed and have heard about appropriate
breastfeeding practice, is important in the development of
sustainable strategies required to improve feeding prac-
tices and thus nutritional status of children.
Abbreviations
AIDS: Acquired immune deficiency syndrome; ANC: Antenatal care;
DHMT: District Health Management Team; DHS: Demographic and health
survey; EBF: Exclusive breastfeeding; FANC: Focused antenatal care;
FGD: Focused group discussions; HIV: Human Immunodeficiency Virus;
IYC: Infants and young children; IYCF: Infant and young child feeding;
MDG 4: Millennium development goal 4; NFNC: Norwegian programme for
development, research and education; U5C: Under five clinic; UNICEF: United
Nations Childrens Fund; WHO: World Health Organization; ZDHS: Zambia
demographic and health survey.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
MK-B and SS contributed to the proposal writing, implementing the study,
analysis and interpretation of data. They also drafted and revised the draft
manuscripts. CK, VM, FM and OB critically analysed and revised draft
manuscripts. All authors read and approved the final manuscript.
Authors information
MK-B -A Paediatrician, public health specialist and researcher currently works
as the National Profession Officer for Child and Adolescent Health at the
World Health Organization, Zambia country office. She is also the WHO focal
person for nutrition.
VM- Currently pursuing a PhD in Public Health, VM was the Director of
Public Health at the Ministry of Health for almost 10 years and worked at the
Ministry headquarters for more than 15 years before he started lecturing at
the Copperbelt University.
CK-A Consultant Paediatrician, lecturer and researcher, currently the Director
of the Paediatric Centre of Excellence for Paediatric HIV/AIDS and PI for the
UTH HIV and AIDS programme (UTH-HAP) at the University Teaching
Hospital.
FM-Currently the National Professional Officer for Malaria, he has more than
22 years experience in research and planning. He holds a PhD and MSc in
medical entomology.
OB-The WHO Representative in Zambia, an epidemiologist, public health
specialist and researcher.
SS-A Professor in medical biostatistics and researcher, he is currently
teaching in the Public Health Unit, Clinical Sciences Department, School of
Medicine, Copperbelt University, Ndola, Zambia.
Acknowledgements
We would like to firstly acknowledge all the mothers and caregiver who
graciously agreed to participate in this study. The research assistants
exhibited a high level of commitment to their work they did a wonderful
job. The technical support from Department of Community Medicine,
University of Zambia was most appreciated. This study was funded by
Norwegian Programme for Development, Research and Education (NUFU)
and United States Agency for International Development (USAID).
Katepa-Bwalya et al. International Breastfeeding Journal (2015): Page 8 of 8

Author details basis for adapting Clinical Guidelines, Feeding recommendation and local
1
World Health Organization, Country Office, Lusaka, Zambia. 2Public Health terms; 1998.
Unit, Clinical Sciences Department, School of Medicine, Copperbelt 23. Ojofeitimi EO, Olagaon AA, Osokoya AA, Owolabai SP. Infant feeding
University, Ndola, Zambia. 3Department of Paediatrics and Child Health, practices in a deprived environment: a concern for early introduction of
University Teaching Hospital, Lusaka, Zambia. water and glucose water to neonates. Nutr Health. 1999;13(1):1121.
24. Armar-Klemesu M, Ruel MT, Maxwell DG, Levin LE, Morris SS. Poor maternal
Received: 27 January 2014 Accepted: 25 January 2015 schooling is the main constraint to good child care practices in Accra.
J Nutr. 2000;130:1597607.
25. Kalanda BF, Verhoeff FH, Brabin BJ. Breast and complementary feeding
practices in relation to morbidity and growth in Malawian infants.
References Eur J Clinical Nutr. 2006;60:4017.
1. Central Statistics Office (CSO), Ministry of Health (MOH), Tropical Disease 26. Aidam BA, Perez-Escamilla R, Lartey A, Adiam J. Factors associated with
Research Centre (TDRC), University of Zambia and Macro International Inc. exclusive breastfeeding in Accra, Ghana. Eur J Clinical Nutr. 2005;59:78996.
Zambia Demographic and Health Survey 2007. Calverton, Maryland, USA: 27. Lartey A, Manu A, Brocon KH, Peerson JM, Davey KG. A randomised
CSO and Macro International Inc.; 2009. community based trial of the effects of improved centrally processed
2. WHO. World Health Statistics Report 2009. Geneva, Switzerland: World complementary foods on growth and micronutrient status of Ghanaian
Health Organisation; 2009. infants from 612 months of age. Am J Clinical Nutr. 1999;70:391404.
3. Black RE, Allen LH, Bhutta ZA, Caulfield LE. Maternal and Child Under 28. Chopra M. Risk factors for undernutrition of young children in a rural area
nutrition, Global and regional exposures and health consequences. of South Africa. Public Health Nutr. 2003;6(7):64552.
Lancet. 2008;371:24360. 29. Greiner T. HIV and Infant feeding: A Report of a WABA UNICEF
4. Central Statistics Office [Zambia], Central Board of Health [Zambia], and ORC colloquium. Arusha, Tanzania. 2002:90.
Macro. Zambia Demographic and Health Survey 20012002. Calverton, 30. WHO. Fifty-fourth World Health Assembly. Resolution WHA 54.2. Geneva,
Maryland, USA: Central Statistics Office, Central Board of Health and ORC Switzerland: Agenda Item 13.1: Infant and young child nutrition; 2001.
Macro; 2003. 31. Saha KK, Frongillo EA, Alam DS, Arifeen SE, Person LA, Rasmussen KM.
5. Gareth J, Steketee RW, Black RE, Bhuuta ZA, Morris SS. The Bellagio Child Appropriate infant feeding practices results in better growth of infants and
Survival Study. How many child deaths can we prevent this year? young children in rural Bangladesh. Am J Clinical Nutr. 2008;87(6):18529.
Lancet. 2003;362:6571.
6. UNICEF. The State of the Worlds Children 2006. Women and Children-The
double dividend of gender equity. New York: UNICEF; 2007.
7. Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, et al.
Infant feeding and deaths due to diarrhoea: a casecontrol study.
Am J Epidemiol. 1989;129:103241.
8. Arifeen S, Black RE, Antelman G, Baqui A, Caulifield L, Becker S. Exclusive
breastfeeding reduces acute respiratory infection and diarrhoea deaths
among infants in Dhaka slums. Pediatrics. 2001;108:E67.
9. Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, Bhandari N, et al. Infant
feeding patterns and risks of death and hospitalisation in the first half of
infancy: multicentre cohort study. Bull World Health Organ. 2005;83:41826.
10. Coutsoudis A, Pilay K, Huhn L, Spooner E, Tsai WY, Coovadia HM. Method of
feeding and transmission of HIV-1 from mothers to children by 15 months
of age: a prospective cohort study from Durban, South Africa.
AIDS. 2001;15:37987.
11. Vaahtera M. Breastfeeding and complementary feeding practices in rural
Malawi. Acta Paediatr. 2001;90(3):32832.
12. Ziyane S. Relationship between infant feeding practices and diarrhoea
infections. J Adv Nurs. 1999;29(3):7216.
13. Kruger R, Gericke GJ. A qualitative exploration of rural feeding and weaning
practices, knowledge and attitudes on nutrition. Public Health Nutr.
2003;6(2):21723.
14. Bellagio Study Group on Child Survival. Knowledge into action for child
survival. Lancet. 2003;362:3237.
15. Seller DW. Infant and young child feeding practices among African
Pastoralists: the Datoga of Tanzania. J Biosoc Sci. 1998;30(4):48499.
16. Agnarsson I. Infant Feeding practices during the first six months of life in
rural area in Tanzania. East Afr Med J. 2001;78(1):913.
17. National Food and Nutrition Impact Survey. Report on Assessment of Practices,
Programmes and Policies on Infant and Young Child Feeding in Zambia.
Lusaka, Zambia: National Food and Nutrition Commission; 2003. p. 79. Submit your next manuscript to BioMed Central
18. Haggerty PA, Rutstein SO. Breastfeeding and complementary feeding and and take full advantage of:
the postpartum effects of breastfeeding. DHS Comparative studies No. 30.
Calverton, Maryland: Macro International Inc; 1999.
Convenient online submission
19. Onofiok NO, Nnanyelugo DO. Weaning foods in West Africa: nutritional
problems and solutions. Food Nutrition Bull. 1998;19:1720. Thorough peer review
20. Mieke F. Complementary foods consumed by 612 months old rural infants No space constraints or color gure charges
in South Africa are inadequate in micronutrient. Public Health Nutr.
2005;8:37381. Immediate publication on acceptance
21. Gibson RS, Ferguson EL, Lehrfeld J. Complementary foods for infant feeding Inclusion in PubMed, CAS, Scopus and Google Scholar
in developing countries: their nutrient adequacy and improvement. Research which is freely available for redistribution
Eur J Clinical Nutr. 1998;52:76470.
22. World Health Organization publication. Integrated Management of
Childhood Illness, Adaptation guide, 1998. Geneva, Switzerland: Technical Submit your manuscript at
www.biomedcentral.com/submit